The Journey to an Incentive-Based Health Equity Quality Index

In July 2021, Indiana University Health (IU Health) embarked on a transformative health equity initiative that began by establishing an Office of Health Equity Research and Engagement (HERE), with a 5-year strategy centered on incorporating equity into its core values and clinical performance improvement. HERE focused its initial work on developing an incentivized equity performance measure for the Promise Dashboard, the health system's leader dashboard. In 2023, the Health Equity Quality Index (HEQI) was added to the Promise Dashboard as a watch metric; the index ranges from 0 to 5, with 5 being the best score. This index prioritizes three major racial disparities: controlled hypertension, completed childhood immunizations, and severe obstetrical complications (SOBCs). The initiative spent 6 months (from April 2022 to October 2022) analyzing historical data to prepare the model and identify initial areas with the largest disparities. This process revealed significant racial (e.g., Black–white) disparities in three clinical areas: cardiovascular, maternal/infant, and behavioral health. The HEQI was then designed to score system-level performance based on these disparities, with an incentivized approach awarding points for maintaining or decreasing the size of the disparity. The index is scored based on 12-month performance levels, relative to the baseline disparity gaps calculated in 2022. No points are awarded if the disparity grows to be greater than the baseline; otherwise, 1–5 points can be awarded for maintaining or decreasing the size of the disparity. A Health Equity Performance Improvement Council (HEPIC), formed in 2023, aligned IU Health with new survey requirements from The Joint Commission and played a pivotal role in implementing health equity plans across its statewide health care system. Unforeseen technical challenges arose in May 2023, impacting the measurement of SOBC levels, owing to a data misclassification error. Subsequent correction unveiled a Black–white disparity trend, requiring a recalibration of strategies. Similarly, achieving hypertension control while simultaneously closing the disparity gap proved challenging. However, focused interventions grounded in evidence, including the deployment of community health workers and remote patient monitoring programs, resulted in progress. Another challenge involved reshaping the cultural mindsets of quality and safety teams. Prior to HEQI, disparities were not considered in clinical decision-making or resource allocation, and disaggregating data to reveal disparities was not standard procedure. Despite hurdles, as of December 2023, childhood immunization disparities have improved by 30%, (reducing the gap by 6.41 points, from the 21% baseline to 14.59%), and the HEQI, which improved from the baseline 1.33 to 1.67, indicates progress, which has been driven primarily by this childhood immunization disparity reduction. This initiative, serving as a testing ground for disparity performance improvement, underscores the importance of data disaggregation, innovative interventions, continuous data analysis, and sustained efforts for advancing health equity at systemic and patient-specific levels.